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APPLICATION FOR PERMIT <br /> SAN JOA4UIN LOCAL HEALTH DISTRICT PERMIT NO. 3 �5 <br /> 1601 E. HAZELTON AVE., <br /> (209) 466-6780 ' CA <br /> 1N <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> f <br /> r in <br /> Application is hereby <br /> yimade toithe <br /> San <br /> de iJoaquin <br /> LocancelwHthlSanth OJoaquin CountypOrdinan�ecNo5t549tfordsewagesorlNoth1862rfor ewell/pump <br /> described. T <br /> and the Rules and Regulations of the San LLJoaquin Local Health District. <br /> Job Address �6�J1� S� �'r/7v7' Tye Subdivision Name <br /> �¢/y Address 2-4 °y S� ��� �'rh v Y Phone <br /> Owner's Name �/�/S/�?'� Phone <br /> Contractor's <br /> Contractor's Names �'r/'Q�' �SA&, License No. <br /> DESTRUCTION V <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ ❑ <br /> PUMP INSil <br /> TALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑! <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANd _ SEWER LINES PITS/SUMPS 03 <br /> 1� <br /> AGRICULTURE WELL OTHER WELL <br /> FOUNDATION <br /> CONSTRUCTION SPECIFICATIONS <br /> _INTENDED DED USE TYPE OF WELL PROBLEM EM AREA pia. of Well Excavation <br /> 1 ❑ Industrial ❑� Open Bottom ❑Manteca <br /> Dia. of Well Casing <br /> ❑� Domestic/Private �]Gr`avel Pack <br /> ❑Tracy <br /> ❑ Public ❑Other ❑Delta Type of Casing <br /> Irrigation Approx. ❑Eastern Specifications <br /> ❑ Cathodic Protection <br /> Depth Depth of Grout Seal <br /> ❑Geophysical Type of Grout <br /> Other Surface Seal installed by <br /> H.P. State Work Done — <br /> Repair Work Done ❑ Type of Pump <br /> Sealing Material (top 50') <br /> Well Destruction f_1 Well DiametIer (Below 50') <br /> Depth Filler Material <br /> E <br /> p� permitted <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION KI REPAIR/ADDITION ❑ (No septic tank or seepage availablewithin u200cis <br /> feet.) <br /> I ,1 <br /> Installation will serve: Residence �X Commercial Other Lot size <br /> Number of living units: Number of bedrooms 2- Water table depth <br /> Character of soil to a depth of 3 feet, A-! h r Capacity _,_ o o No. Compartments <br /> SEPTIC TANK W1 Type/Mfg f e CfJtT <br /> Capacity �� Method of Disposal ` <br /> PKG. TREATMENT P.LT. ❑ Type/Mfg Line 5 o <br /> SEWAGE SYSTEM Distance to nearest: Well fs0 Foundation 16, Property <br /> DESTRUCTION r '2 J 7 <br /> Total length/size <br /> LEACHING LINE ❑ No. &- Length of lines /p <br /> ! 00 , Foundation Property Line <br /> FILTER BED � Distance to nearest: Well Z <br /> Size Number <br /> SEEPAGE PITS ❑ Depthproperty Line <br /> Distance to nearest: Well Foundation �� <br /> SUMPS U ! C <br /> DISPOSAL PONDS ❑ <br /> f prepared this application and that the work will be done in accordance with San Joaquin county <br /> 1 hereby certify that I have <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. rmance of <br /> Home owner or licensed agent's <br /> signature certifies <br /> suchFinannernas to becomeythat subjectntohworrkman� compensatianwlawsfof California. <br /> permit is issued, I shall not <br /> employ y P erformance of the work for which <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the p { <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant mus call for 11 required inspections. Complete drawing on reverse side. pate. 4- <br /> Title: <br /> Signed X <br /> OR ARTMENT USE ONLY Area Q ❑ Stk 466-6781 <br /> Application Accepted by ❑ Lodi 369-3621 <br /> Additional Comments: Date ❑ Manteca 823-7104 <br /> Pit or Grout Inspection by Date ❑ Tracy 835-6385 <br /> f Final Inspection by <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9 , <br /> FEE BASE BUNT DUE AMOUNT REMITTED <br /> RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 — <br />